RN Care Management Practice Improvement Specialist

H3S Clackamas Health Centers
$44.00 - $55.85 Hourly/DOE

Clackamas Health Centers (CHC) seeks an experienced RN Care Management Practice Improvement Specialist to collaborate with Clinical Leadership in elevating the scope of practice for registered nurses within an ambulatory care setting. This is a temporary, hybrid/remote position. The primary objective of the RN Care Management Practice Improvement Specialist position is to contribute to the development of an RN Chronic Care Management program that improves outcomes for patients with chronic health conditions, supports transitions of care, promotes patient self-management efficacy, and reduces the risk of ED Utilization and Hospitalization for vulnerable populations. The goal is to contribute to CHC’s new Population Health Team by developing the RN care management role to mitigate risk, improve patient safety, and expand the skill of registered nurses in delivering high-quality care management.

The RN Care Management Practice Improvement Specialist will, together with nursing and medical leadership, design, implement, and develop sustainability guidelines for an RN-led CCM program to improve patient outcomes, enhance care coordination, and optimize chronic disease management strategies. Moreover, the RN Care Management Practice Improvement Specialist will play a crucial role in advancing value-based care initiatives, which are essential for the sustainability and efficiency of healthcare delivery. They will provide expertise in guiding and developing nursing protocols that enhance RN-provider collaboration, strengthen certified medical assistant competencies, and establish evidence-based standards of care. This role is vital to improving patient outcomes and the efficiency of health care delivery at Clackamas Health Centers.

Key Responsibilities

Program Development and Implementation:

• Serve as an expert resource for developing an RN Chronic Care management program including developing process steps such as eligibility, enrollment, consent, program delivery, care planning, and successful billing.
• Create a training program for RNs to perform chronic care management.
• Develop key metrics for guiding implementation and sustainability of the program
• Develop workflows, protocols, and standing orders to support RN-driven chronic disease management.
• Establish risk stratification criteria and population health strategies to identify high-risk patients.
• Ensure compliance with Medicare CCM billing requirements, Medicaid regulations, and value-based care models.
• Collaborate with EHR Systems Analysts to implement EHR-integrated care management tools.
• Develop and implement quality assurance standards, protocols, and policies related to chronic care and transitional care management for registered nurses, certified medical assistants, patient care coordinators, and other allied health roles.
• Ensure clinical practice standards align with the latest evidence-based practices.
• Contribute to population health initiatives that promote value-based care, ensuring sustainable and efficient healthcare delivery models.

Why Join Clackamas Health Centers?

• Opportunity to lead and shape innovative nursing programs in a dynamic healthcare environment.
• Flexible, hybrid/remote work setting
• Work with a mission-driven organization dedicated to serving vulnerable populations.
• Collaborative and supportive leadership team.

If you are a forward-thinking nursing professional eager to make a significant impact in patient care management and population health program development, we invite you to apply for this exciting opportunity at Clackamas Health Centers.

Minimum Qualifications

• Active Registered Nurse (RN) license in the state of Oregon.
• Minimum of five years of nursing experience including care management/care coordination, preferably in an ambulatory care setting.
• Experience developing and implementing care management programs for patients with chronic conditions (e.g., diabetes, heart failure, COPD).
• Experience with motivational interviewing, trauma informed care and therapeutic RN best practice techniques.
• Proficiency in EHRs, data analytics, and care management software.
• Ability to collaborate effectively with multidisciplinary teams and influence clinical operations.
• Excellent communication, leadership, and problem-solving skills.
• Experience creating training materials, program guides, workflows and/or job aids.

Preferred Qualifications

• Experience in a Federally Qualified Health Center or Community Health Setting
• Bachelor’s degree in Nursing
• Certified Case Manager (CCM) or other case management certifications (e.g., ACM, CCTM)
• Master’s Degree in Nursing (MSN)
• Experience in managed care, accountable care organizations (ACO), or value-based care models.
• Knowledge of social determinants of health (SDOH) and community resources.
• Experience with telehealth and remote patient monitoring.
• Experience launching new care coordination programs in ambulatory or primary care settings.
• Leadership experience in program development or quality improvement initiatives
• Experience working with underserved populations

Schedule

Flexible working hours, Remote/Hybrid options

Duration

6 Months

How to Apply

1. Please submit a cover letter (limited to one page) and resume to Juliana Danforth at jdanforth@clackamas.us
2. ATTN: re: Nurse Leader position in the subject line.
3. Position will be open until filled. First application review date will be: March 17 at 5 p.m.
4. If requesting veterans’ preference points under eligibility criteria of ORS 408.230-408.235, please submit supporting documentation to jobs@clackamas.us. When submitting documentation please reference the posting job title and department in your email.

For more information, please feel free to reach out to Juliana Danforth at jdanforth@clackamas.us.